家庭医生签约服务驱动社区骨健康管理的模式探讨

【关键词】骨健康管理；家庭医生签约服务；全周期闭环模式；智能分层预警；多学科协作【中图分类号】 R681 【文献标识码】 ADOI：10.12114/j.issn.1007-9572.2025.0179

【Abstract】Withtheintensificationofpopulationaging，bonehalthdiseases （e.g.osteoporosis，osteoarthritis，oliosis） havebecomeamajorpublic healthchallngeinChina.Traditional healthcare models，centeredonacute-phasediagnosisand treatment，suferfromshortcomingssuchasoveremphasisontreatmentoverprevention，fragmentedservices，ndinadequate continuityofehabilitatio，leadingtolowarlysreeningrates，oorpatientcompliance，ndhighcuencerisks.isstudy analyzesthecorecharacteristicsandmanagementbotlenecksofbonehealthdiseasesDrawingonintermationalchronicdisease managementframeworksanddomesticpracticalexperience，andleveragingtheresourceintegrationadvantagesoffamilydoctor contractedservices，weinnovativelyconstructeda"smarthierarchicalearlywaing-ultiisciplinarycollborativeintervetion integrated medicalandpreventivecare"modelforfull-cycleclosed-lopmanagementofbonehalth，aiming toaddresssystemic challngesinbonehalthmanagement.Theinnovationofthisstudyliesinenhancing managementeficiencythroughintellgent tols，optimizingresourcealocationviamultiisciplnarycollboration，andstrengtheningtesustaiabilityofhalthcaresvices through policy reforms，thereby providing asystematic paradigm for grassroots bone health management.

【Key words】Bone health management; Family doctor contracted services;Full-cycle closed-loop model; Smart hierarchical early warning;Multidisciplinary collaboration

老龄化社会背景下，我国骨伤科疾病谱发生了重要转变，从以急性创伤性疾病为主，逐步转变为以慢性退行性骨与关节疾病、骨代谢疾病、运动损伤等疾病为主[］。（剩余16136字）